How I treat patients with recurrent venous thromboembolism despite intensive anticoagulation
Anand Lokare
pp 1-5
Recurrent venous thromboembolism (VTE) after cessation of anticoagulant therapy is well recognised, but very little literature exists about the management of recurrent VTE while the patient is still on therapeutic anticoagulation (anticoagulation failure), as this is rare. This review looks at possible causes and suggests some interventions to manage this situation.
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Comment: Catheter-related complications
Peter Rose
pp 2-2
Catheter-related deep vein thrombosis (DVT) of the upper limb is an ever-increasing concern, particularly in the haemato-oncology field. Debate continues regarding the best methods for diagnosis, management and prevention. Strategies to prevent line thrombosis have largely been proven ineffective. The International Society on Thrombosis and Haemostasis (ISTH) has recently produced guidelines for catheter-related thrombosis, which will aid those involved in the management of such patients.
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Redesigning a deep vein thrombosis pathway
Greg Fell
pp 6-7
The EINSTEIN study established the efficacy and safety of rivaroxaban for the treatment of symptomatic deep vein thrombosis (DVT), without the need for coagulation monitoring. It offered a simple, single-drug approach to the short-term, continued treatment of DVT. Historically, in Bradford, most patients with suspected DVT were admitted to hospital for diagnosis and, if confirmed, they were discharged on low molecular weight heparin (LMWH) and warfarin with community monitoring until stable. Following this, due to a lack of formal DVT follow-up clinics, patients were monitored in hospital anticoagulation clinics. This resulted in patients experiencing significant delays in receiving treatment in an already busy A&E department and medical assessment unit (MAU). There is widespread acceptance, with good supporting evidence, that the majority of non-complex patients could be managed in an outpatient setting.
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FAQs: How to assess stroke and bleeding risks in atrial fibrillation
Gregory YH Lip
pp 8-9
Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, and confers a substantial risk of mortality and morbidity from stroke and thromboembolism. While the risk of stroke in AF is increased fivefold, it is not homogeneous. Thus, a crucial part of AF management is the appropriate use of thromboprophylaxis.
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Long-term secondary prevention of venous thromboembolism: warfarin, oral direct inhibitors or aspirin?
Gordon Lowe
pp 10-11
The standard therapy for acute venous thromboembolism (VTE) is three to six months of treatment with anticoagulant drugs. Traditionally, this is with heparin (usually a subcutaneous, low molecular weight heparin) overlapping with oral warfarin. Recently, novel oral direct inhibitors (ODIs) have been studied as alternative anticoagulation. These drugs include the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban and apixaban. They are effective in fixed doses and, unlike warfarin, do not require regular monitoring of their anticoagulant effect and dose adjustment. A recent systematic review and meta-analysis of randomised controlled trials of these drugs versus warfarin has shown that they are similarly effective to warfarin for the risk of recurrent VTE.1Major bleeding episodes were less common in patients receiving rivaroxaban.
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Delivering anticoagulation services - a call to arms for primary care
David A Fitzmaurice
pp 12-14
The history of medicine is littered with examples of practice that would seem incongruous today, yet were perfectly acceptable at the time. Tasting urine to diagnose diabetes and the use of horse dung to clean wounds date from ancient times; however, surgical intervention to treat an infectious disease in the form of vagotomy (resection of the vagus nerve) and pyloroplasty (widening of the lower stomach) was a mainstay of medical practice until very recently. Similarly, it was not that long ago that patients were admitted overnight to commence treatment with angiotensin-converting enzyme inhibitors.
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